Patient LFT Reporting Form

Last updated: 24 May 2023 at 14:05

Patients Information

Name*
Patients First Name Surname
Patients Date of Birth*
DD slash MM slash YYYY
Test Information
Unit Number (Hospital Number from SemaHelix)*
Lot Number of Test*
Tested Person Type*
Reason for Testing*
If none of these apply, does the patient need to be tested?
If 'Other' was selected on the above, please provide more details here:
Date Test was Taken*
DD slash MM slash YYYY
Time Test was Taken (please use 24-hour format)*

: Hours

Minutes
Test Result (Please see the testing guide for details of how to interpret results shown on the device.)*
- Positive
- Negative
- Invalid
Patient Informed?*
- Yes
- No
Test Taken By:*
First Name Last Name
Job Role/Title:*
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